Personal Data Inventory

Please fill out this form with as much information as you can and click submit.

General Information

Name

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Email

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This address will receive a confirmation email

Phone

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Address

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Occupation

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Birth Date

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Age

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Marital Status

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Education (last year completed)

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Other training

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Emergency Contact Name

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Emergency Contact Phone

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Health Information

Rate your physical health (1-10)

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What is the date of your last medical exam?

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Were there any significant outcomes of the medical exam?

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Please list all important present or past illnesses, injuries, or handicaps.

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Are you presently taking any medications? If so, what?

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Have you ever had a severe emotional upset?

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Have you ever been arrested?

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Have you recently lost someone who was close to you?

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Have you recently suffered loss from serious social, business, or other reversals/setbacks?

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Religious Background

Do you attend church regularly?

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Church name:

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Are you a member?

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Attendance per month?

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Did you attend church in your childhood?

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Religious Background of spouse (if married):

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Do you consider yourself a religious person?

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Do you believe in God?

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Do you pray to God?

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Are you saved?

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How much do you read the Bible?

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Do you have regular family devotions?

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Personality Information

Have you ever had any psychotherapy or counseling?

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If yes, list counselor or therapist dates:

What was the outcome of the counseling?

Check any of the following words which best describe you now:

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Please select all that apply.

Active Ambitious Self-Confident Persistent Nervous Hardworking Impatient Impulsive Moody Often-blue Imaginative Excitable Calm Serious Easy-going Shy Good-natured Introvert Extrovert Likeable Leader Follower Quiet Submissive Lonely Self-conscious Sensitive Other

If other, please explain:

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Have you ever felt people were watching you?

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Do people's faces ever seem distorted/disoriented?

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Do you ever have difficulty distinguishing faces?

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Do colors ever seem too bright?

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Are you sometimes unable to judge distance?

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Have you ever had hallucinations?

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Do you have problems sleeping?

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Marriage and Family Information

Name of spouse

Spouse's phone

Spouse's address

Spouse's occupation

Spouse's age

Spouse's education

Is your spouse willing to come to counseling?

Have you ever been separated?

Date of marriage?

Age of husband when married?

Age of wife when married?

How long did you know your spouse before marriage?

Length of steady dating with spouse?

Length of engagement?

Children's name(s):

Children's age(s):

Children's gender(s):

Are all your children living?

Are any of your children married? If so, list them.

Do you have any children from a previous marriage?

How many older brothers do you have?

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How many younger brothers do you have?

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How many older sisters do you have?

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How many younger sisters do you have?

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Additional Information

In terms of why you are seeking counseling, what is your problem?

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What have you done about it?

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What can we do (what are your expectations in coming here)?

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As you see yourself, what kind of a person are you? Describe yourself.

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What, if anything, do you fear?

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Is there any other information we should know?

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Description

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